Version May 2024
INTRODUCTION — The clinical features and diagnosis of the substance-exposed child (SEC, also called the "drug endangered child") will be discussed here.
The management of the SEC, substance use in pregnancy, infants with prenatal substance use exposure, neonatal drug withdrawal, and medical child abuse including maliciously giving medications or drugs to children to cause illness are covered separately:
●(See "The substance-exposed child: Management".)
●(See "Substance use during pregnancy: Overview of selected drugs" and "Substance use during pregnancy: Screening and prenatal care".)
●(See "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Management and outcomes".)
●(See "Medical child abuse (Munchausen syndrome by proxy)".)
TERMINOLOGY — The "substance-exposed child" (SEC, also called the "drug endangered child") refers to infants and children harmed or at risk of harm by exposure to drugs or other substances and/or an unsafe home environment related to parent or caregiver substance use. Exposures to either licit (tobacco/nicotine, alcohol) or illicit substances (drugs used recreationally with high abuse potential, such as cocaine, heroin, cannabis in some regions) may adversely impact the health and safety of the SEC [1,2].
Harm to the SEC may result from any one of the following [1-12] (see 'Clinical features' below):
●Child intoxication caused by inadvertent or intentional exposure to drugs or other substances
●Child injury:
•Burns or caustic ingestion due to exposure to hazardous chemicals used in the manufacturing of illicit drugs
•Burns or wounds due to contact with unsafe drug paraphernalia (eg, needles, razor blades, or heated cookware) and potential transmission of bloodborne pathogens such as HIV and hepatitis B and C
●Impaired parent or primary caregiver resulting in an unsafe home environment and child abuse and neglect
●Exposure to violence caused by the parent's or caregiver's possession, manufacturing, production, cultivation, or distribution of legal or illegal substances
●Forced participation in illegal or sexual activity in exchange for drugs or money to obtain drugs for the parent or primary caregiver
Caregiver substance use and drug endangerment is variably addressed in civil and/or criminal child abuse and neglect statutes across the United States. Across both national and international jurisdictions, caregiver substance use may represent neglect, child endangerment or even result in felony prosecution [13]. Examples of harmful exposures that may result in legal sanctions include [13]:
●Parent or caregiver use of controlled substances that impairs their ability to adequately care for the child
●Selling, distributing, or administering drugs or alcohol to a child
●Manufacturing a controlled substance in the presence of a child or within the home in which a child lives
●Exposing a child to, or permitting a child to be present where toxic precursor chemicals or equipment for the manufacture of controlled substances are used or stored
●Exposing a child to the criminal sale or distribution of drugs
●Exposing a child to drug paraphernalia
Infants of mothers with substance use disorder are a special category of SEC whose families often warrant additional protective intervention, resources, and community-based support. The evaluation and management of these infants is discussed in detail separately. (See "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Clinical features and diagnosis" and "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Management and outcomes".)
EPIDEMIOLOGY — Approximately one in eight children in the United States reside in households with a caregiver experiencing problematic substance use that results in impaired functioning [14]. It is therefore highly likely that healthcare professionals treating either adults or children, irrespective of medical specialty, will interact with families affected by substance use in clinical practice [15].
The substance-exposed child (SEC) has a heightened risk for serious injury and other adverse outcomes including [5-9]:
●Acute poisoning, especially due to ingestion of opioids (eg, heroin, methadone, buprenorphine, or fentanyl) or methamphetamine
●Acute and chronic exposure to hazardous chemicals used during illegal manufacturing of drugs (eg, methamphetamine production is associated with exposure to phosphorus, lye, acids, and iodine)
●Physical, sexual, or emotional child abuse
●Neglect (physical, emotional, educational, and/or medical)
●Impaired cognitive, social, or emotional development caused by exposure to a chaotic living environment and caregiver neglect [13,16,17]
●Disproportionate out-of-home foster care placements related to impaired parenting, placement instability, and child abuse or neglect concerns [4,10,13,18-24]
In addition, a significant proportion of child maltreatment fatalities involve a caregiver with problem substance use [10].
While interaction with an overtly intoxicated SEC or caregiver may be obvious, asymptomatic exposure in the SEC requires a high index of clinical suspicion, especially among children undergoing evaluation for abuse or neglect [18-20]. For example, in a cross-sectional study of children evaluated for physical child abuse, occult drug exposure was detected by urine testing in up to 8 percent of individuals with intermediate to high concern for abuse [18]; detection rate may be higher among centers utilizing hair testing methodology, but interpretation of these results requires expertise [19,25]. (See 'Toxicology testing' below.)
Commonly implicated substances in the SEC include:
●Opioids (prescription medications, methadone, fentanyl [including synthetic fentanyl], and heroin) (see "Opioid intoxication in children and adolescents")
●Cannabis (see "Cannabis (marijuana): Acute intoxication")
●Methamphetamine (see "Methamphetamine: Acute intoxication", section on 'Pediatric considerations')
●Cocaine (see "Cocaine: Acute intoxication", section on 'Pediatric considerations')
Although major poisoning with life-threatening toxicity and death from illicit drug intoxication in infants and young children is rare, asymptomatic or minor exposures are more frequently reported to regional poison control centers [2]. These findings suggest that the illicit drug exposures were likely identified due to a history of suspected exposure, concerns for caregiver substance use, or performance of drug screening during medical or social evaluation.
CLINICAL FEATURES — Clinical features include findings of substance exposure, injuries related to an unsafe environment, and/or evidence of child abuse.
Findings of substance exposure — The presentation of a substance-exposed child (SEC) occurs on a continuum varying from physical manifestations of life-threatening intoxication to asymptomatic children with positive toxicology testing [2,4,11,26]:
●Poisoning – The SEC may present with signs of unintentional or malicious poisoning due to agents such as opioids (see "Opioid intoxication in children and adolescents"), cannabis, or methamphetamine (table 1) (see "Approach to the child with occult toxic exposure"). Opioid poisonings in infants may occur in an attempt to sedate the child. (See "Medical child abuse (Munchausen syndrome by proxy)", section on 'Perpetrator actions'.)
Symptoms exhibited by young children after cannabis and methamphetamine exposure may vary from classic toxidromes. For example, children exposed to concentrated forms of cannabis may present with coma and respiratory depression rather than the expected findings of mild sympathomimetic effects with vomiting, conjunctival injection, nystagmus, and/or ataxia (see "Cannabis (marijuana): Acute intoxication", section on 'Children'). Similarly, children with cocaine or methamphetamine poisoning may exhibit lethargy rather than agitation, although the typical sympathomimetic effects (agitation, dilated pupils, tachycardia, hypertension, diaphoresis, and seizures) still frequently occur [2]. (See "Methamphetamine: Acute intoxication", section on 'Pediatric considerations'.)
●Hazardous chemical exposure resulting in burns, caustic ingestion, or inhalational injury – Although uncommon, hazardous chemical exposure in children has been described, typically in drug-endangered children living in houses used as clandestine methamphetamine laboratories [27,28]. Chemicals potentially used during household methamphetamine production and the range of clinical effects include [27,29]:
•Caustic agents (eg, sulfuric, hydrochloric, or phosphoric acid and sodium hydroxide) – Chemical burns of the skin and eyes, caustic ingestion (see "Topical chemical burns: Initial evaluation and management" and "Caustic esophageal injury in children")
•Anhydrous ammonia – Chemical burns of the skin and eyes, cold injury; inhalation can cause laryngospasm, upper airway burns, pulmonary injury, and edema (see "Topical chemical burns: Initial evaluation and management", section on 'Anhydrous ammonia')
•Organic solvents (eg, acetone, toluene, trichloroethane, and freon) – Agent-specific toxicities are provided in the table (table 2) and discussed separately (see "Acute hydrocarbon exposure: Clinical toxicity, evaluation, and diagnosis", section on 'Hydrocarbon inhalation')
•Fuels (eg, kerosene or gasoline) – Hydrocarbon pneumonitis, skin or eye burns (see "Acute hydrocarbon exposure: Clinical toxicity, evaluation, and diagnosis")
•Crystallized iodine – Caustic ingestion or inhalational lung injury
•Phosphorus – Caustic ingestion; delayed multisystem organ failure (liver, kidneys, and heart) (see "Overview of rodenticide poisoning", section on 'Elemental phosphorus')
•Phosphine gas (produced by combining red phosphorus with iodine) – Direct cardiac toxicity associated with refractory hypotension and cardiac arrhythmias, hemorrhagic pulmonary edema with acute respiratory distress syndrome (see "Overview of rodenticide poisoning", section on 'Zinc and aluminum phosphide')
●Exposure to unsafe drug paraphernalia – Skin or needlestick injuries from razor blades, syringes, or heated cookware may occur after contact with unsafe drug paraphernalia. In addition to indicating likely drug exposure and need for toxicology testing, they pose a risk of transmission for bloodborne pathogens such as HIV, hepatitis B, and hepatitis C.
●Impaired caregiver or evaluation after rescue from a clandestine drug laboratory (potential exposure) – In this circumstance, the SEC may be asymptomatic or minimally symptomatic but exposed. Such occult exposures require detection by toxicology testing [2,18-20]. (See 'Toxicology testing' below.)
Signs of child abuse — In addition to evidence of drug exposure, the SEC may have findings of child abuse [4,10,13,21,22,30,31]:
●Physical child abuse – Common findings include bruises, burns, fractures, and/or other injuries that are suspicious or unexplained (table 3 and table 4). (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management".)
●Sexual abuse – For children who are sexually abused, disclosure of sexual molestation on history is the most important finding; a normal physical examination does not exclude sexual abuse. Clinical findings are provided in the table (table 5). In addition to sexual abuse by a caregiver or family member, the SEC may be sexually exploited to obtain money or drugs for the caregiver. Evaluation for sexual abuse is discussed separately. (See "Evaluation of sexual abuse in children and adolescents".)
●Neglect – Clinical findings of neglect may present as poor hygiene, lack of adequate clothing or diapers, signs of starvation, failure to thrive, or serious injury caused by lack of appropriate supervision or inadequate protection from drug-related violence. The child may also demonstrate impaired cognitive, social, or emotional development related to a chaotic living environment or inadequate supervision. Older children may have chronic school truancy. (See "Child neglect: Evaluation and management".)
●Emotional abuse – The SEC often lacks caregiver love and affection and is exposed to a dangerous environment with little emotional support. In addition, the child may be demeaned, criticized, threatened, or rejected by the caregiver. These experiences may manifest as withdrawal, passivity, poor social development, acting out behavior, anxiety, depression, or post-traumatic stress disorder. (See "Anxiety disorders in children and adolescents: Assessment and diagnosis" and "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis" and "Posttraumatic stress disorder in children and adolescents: Epidemiology, clinical features, assessment, and diagnosis".)
DIAGNOSIS — The diagnosis of a substance-exposed child (SEC) is based on evidence of harm or risk of harm caused by drug or substance exposure due to caregiver actions such as [2]:
●Impaired caregiver – Interaction with, or exposure to an overtly impaired caregiver renders a child unsafe, inadequately supervised, and/or at high risk for serious illness, injury, physical harm, or clinically occult substance exposure.
●Poisoning or substance exposure – For the asymptomatic child found living in a home used for illicit drug manufacturing or distribution (eg, methamphetamine or synthetic fentanyl) or cultivation (eg, marijuana or psychedelic mushrooms), the diagnosis of SEC can be made by signs of child abuse and/or positive toxicology testing. Testing must evaluate for acute as well as chronic substance exposure, which requires enhanced, specialized urine toxicology testing and occasionally the use of hair testing. (See 'Toxicology testing' below.)
Clinical signs, symptoms and/or positive toxicological test results consistent with poisoning or environmental exposure, including exposure to hazardous chemicals used in illicit drug manufacturing (eg, hydrocarbon pneumonitis, chemical burns, inhalational injury, or caustic ingestion) provide acute confirmation of drug or substance exposure. (See 'Findings of substance exposure' above.)
Among symptomatic SECs, common findings of poisoning due to specific drugs (table 1) include:
•Opioid poisoning:
-Coma
-Respiratory depression progressing to apnea, bradycardia, hypotension, and hypothermia
-Miosis (often pinpoint pupils)
-Decreased muscle tone with hyporeflexia
•Sympathomimetic poisoning (methamphetamine or cocaine):
-Agitation/irritability which can progress to seizures
-Hyperthermia, tachycardia, tachypnea, and hypertension
-Dilated pupils
-Excessive sweating with cold, clammy skin
-Increased bowel sounds
•Cannabis – Limited exposure (see "Cannabis (marijuana): Acute intoxication", section on 'Children'):
-Tachycardia with hypertension
-Conjunctival injection (red eye)
-Vomiting
-Nystagmus
-Ataxia
-Slurred speech in verbal children
In large overdoses (eg, ingestion of edible products, concentrated oils, or hashish), coma with apnea or depressed respirations can occur. Although uncommon, seizures have been reported.
•Physical injuries – Puncture wounds or other injuries (eg, lacerations or burns) caused by unrestricted access to drug paraphernalia (eg, needles or razor blades).
Children presenting for evaluation of possible substance exposure warrant careful consideration of co-existing child abuse including evaluation for physical, sexual, emotional abuse and/or neglect. (See "Physical child abuse: Diagnostic evaluation and management" and "Evaluation of sexual abuse in children and adolescents" and "Child neglect: Evaluation and management".)
In addition, some children presenting with suspected child abuse may warrant toxicologic screening. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Toxicology'.)
DIAGNOSTIC EVALUATION
Approach — The evaluation of the substance-exposed child (SEC) focuses on identifying the drug or substance exposure that is endangering the child and the effects and risks from exposure. It includes all of the following [1,4,22,32]:
●Thorough history and physical examination
●Assessment of family interaction
●Toxicological testing
●Diagnostic evaluation for children with signs of co-occurring abuse or neglect
Key clinical questions when evaluating the SEC include (see 'Clinical features' above):
●Poisoning or substance exposure – Is there history, clinical signs or symptoms or toxicological test results indicating systemic or environmental substance exposure, such as signs of poisoning or contact with harmful chemicals involved in substance manufacturing or clinically occult substance exposure? Historical information and evidence shared by child protective services, law enforcement, social work professionals, paramedics, or first responders is vital.
●Unsafe environment – Is there reason to suspect that safe disposition of the child cannot be assured without additional protective intervention (eg, family interaction identifies that the primary caregiver is impaired)?
●Social history – Have co-occurring psychosocial adversities been identified (eg, housing or food insecurity), that warrant referral to community-based resources or other supportive services/programming?
●Co-existing child abuse – Does the child exhibit any co-occurring signs of physical, sexual, emotional abuse and/or neglect that require further evaluation?
●Reporting – Have child safety concerns been reported to appropriate authorities, including child protective services and/or law enforcement?
History — Obtaining an accurate history from a parent/primary caregiver when evaluating an SEC is often challenging:
●Caregivers may exhibit reluctance to share details of substance use (out of concerns for civil or criminal penalties)
●Caregivers may be overtly impaired or intoxicated
●Caregivers may be unavailable due to legal intervention (such as arrest) or co-occurring physical or mental health issue (resulting in hospitalization)
For this reason, historical information and evidence shared by child protective services, law enforcement, social work professionals, paramedics or first responders may be vital. Specific scene investigation (such as substance presence, paraphernalia, specific chemical precursors, poor living conditions or observation of impaired adults exhibiting particular toxidromes) can help guide toxicological testing, communicable disease assessment, and/or evaluation for co-occurring child abuse or neglect [33]. (See 'Toxicology testing' below.)
If available, recent child safety concerns (such as recent hotline reports and/or investigations regarding physical, sexual, emotional abuse and/or neglect, or prior history of prenatal substance exposure) may indicate the need for child abuse evaluation. (See "Physical child abuse: Diagnostic evaluation and management" and "Evaluation of sexual abuse in children and adolescents".)
Review of primary care records and/or social work notes that document relevant family and social history may yield additional important information about environmental risk factors and aid in identification of siblings/household contacts who require evaluation.
Physical examination — The SEC warrants a thorough physical examination with attention to the following findings [4,11]:
●Evidence of neglect such as poor hygiene, inadequate clothing or diapers, malnutrition (failure to thrive), poor dentition, untreated medical condition, or injury caused by inadequate supervision (see "Child neglect: Evaluation and management", section on 'Evaluation')
●Red flag injuries suggesting child physical abuse (table 6) (see "Physical child abuse: Recognition")
●Clinical findings associated with sexual abuse (table 5) (see "Evaluation of sexual abuse in children and adolescents")
●Clinical findings of sexual assault or sex trafficking (table 7) (see "Evaluation and management of adult and adolescent sexual assault victims in the emergency department" and "Human trafficking: Identification and evaluation in the health care setting")
The SEC may also present with physical findings of serious poisoning or injury. The table provides signs and symptoms by common toxins (table 1). In the most serious exposures, findings may include:
●Lethargy or coma with respiratory depression suggesting opioid intoxication or marijuana intoxication (see "Opioid intoxication in children and adolescents" and "Cannabis (marijuana): Acute intoxication", section on 'Children')
●Agitation, seizures, tachycardia, tachypnea, hypertension, and hyperthermia pointing to sympathomimetic intoxication (eg, methamphetamine or cocaine) (see "Methamphetamine: Acute intoxication" and "Cocaine: Acute intoxication")
●Severe eye and airway irritation with tearing blepharospasm, rhinorrhea, drooling, hoarseness, stridor, wheezing, and respiratory distress due to inhalational injury from phosgene or anhydrous ammonia
●Chemical burns to the skin (picture 1) or eyes (picture 2), with or without signs of caustic ingestion (eg, oral burns (picture 3), drooling, dysphagia, or chest pain [may initially be asymptomatic]) from caustic chemical exposure (eg, sulfuric or hydrochloric acid, sodium or potassium hydroxide, or concentrated ammonia) (see "Topical chemical burns: Initial evaluation and management" and "Caustic esophageal injury in children")
Of these potential exposures, ingestion of concentrated sulfuric acid by unsupervised toddlers resulting in severe burns to the perioral skin, oropharynx, upper airway, esophagus and gastrointestinal tract have been reported [27,28].
Family interaction — Interaction with a suspected or obviously impaired caregiver may occur across a variety of scenarios, including accompaniment of the SEC to a medical appointment, such as a routine primary care appointment unrelated to abuse/neglect or SEC concerns. (See "The substance-exposed child: Management", section on 'Child of an impaired caregiver'.)
Screening caregivers from families known to be experiencing problem substance use for co-occurring psychosocial adversities (intimate partner violence, mental health concerns, economic insecurity) is important to facilitate appropriate linkage to community-based resources and supportive programming [4,34-36].
Toxicology testing — Toxicological testing is an essential component in the evaluation of the SEC [4,18-20,37-40]. However, healthcare professionals should not rely solely on a positive or negative toxicology test to make the diagnosis; test results should be interpreted within the broader context of home environment and the child's safety [12,41].
●Indications – Indications for testing include:
•History or physical findings of drug or illicit substance poisoning or exposure in the child, including history obtained from objective third party observers (eg, social workers, prehospital medical personnel, and/or police)
•Parent/primary caregiver impairment (directly observed by the clinician, reported by an objective observer, or suspected by history)
•Concern for co-occurring physical, sexual, emotional abuse and/or neglect (see "Physical child abuse: Diagnostic evaluation and management", section on 'Toxicology')
In some jurisdictions, evidentiary toxicology testing for the SEC during medical treatment may result from legal intervention (issuance of subpoenas or law enforcement warrants) [4,42]. Complying with these requests for testing should consider whether testing is also indicated for the health and safety of the child. Although this is the case in most instances, toxicological testing for purposes other than child health and safety typically requires informed consent of the legal guardian. Obtaining testing specifically for criminal justice purposes without informed consent is problematic in many jurisdictions [43].
●Chain of custody – When obtaining toxicologic testing in the SEC, it is advisable to collect and transport samples using a traceable chain of custody, including careful documentation. Laboratory results for samples for which a chain of custody is not maintained may still be used as evidence, but problems establishing validity may arise. (See "Testing for drugs of abuse (DOAs)", section on 'Chain of custody for evidence'.)
●Recommended testing – Specific toxicology testing for suspected substance exposure varies based upon clinical findings and regional illicit substance use trends:
•Drugs of abuse testing – Toxicology testing should be obtained in children with suspected substance exposure. Commonly available testing usually consists of urine screens for drugs of abuse. For children with a known exposure to a clandestine drug laboratory, urine should be obtained as soon as possible after the last exposure, ideally within 6 to 12 hours [29]. Substances detected, time frame for detection after acute exposure, and potential causes of false positives are summarized in the table (table 8).
Advantages of urine specimens include:
-Ease of collection
-Prolonged duration of excreted parent substances and metabolites that permit longer detection windows compared with serum
-During use in clinical settings, greater reliability than saliva testing
All positive results on initial drugs of abuse screens require confirmation with advanced laboratory methods (eg, gas chromatography with mass spectrophotometry [GC-MS], high performance liquid chromatography [HPLC] with MS, or HPLC with tandem MS). Interpretation of results requires specific knowledge of the assay used for toxin detection and correlation with clinical findings. Consultation with a medical toxicologist (available through a regional poison control center) is encouraged. Interpretation of drugs of abuse tests are discussed in greater detail separately. (See "Testing for drugs of abuse (DOAs)".)
Expanded ("comprehensive") drug screens are available in some institutions and can evaluate for novel synthetic analogues or over-the-counter, non-prescribed and prescribed pharmaceuticals (inappropriately used, not as directed) which frequently go undetected on standard urine drug screens. Advanced methods used for confirmation of drug screens are commonly employed by urine expanded/comprehensive drug screens. Studies suggest a combination of historical information and performance of expanded/comprehensive drug screens detect more substances than standard urine drug screens alone, including among SEC undergoing abuse evaluations and pediatric patients presenting with unknown substance ingestions [38,44-47]. When clinical suspicion of poisoning is high, the clinician should obtain and store an additional 10mL of urine to facilitate completion of expanded drug testing. While expanded/comprehensive drug screen performance can aid in additional substance detection, results may not be available for several days to weeks [45].
•Assays for synthesized illicit drugs – It may be necessary to specifically request an assay for illicit drugs that may not be included or detected on the available screen for drugs of abuse (eg, fentanyl, fentanyl analogs, or synthetic cannabinoids). Illicit substance use trends in the local community are available from regional poison control centers and law enforcement. Consultation with a medical toxicologist or clinical laboratory specialist with similar expertise assists with identification of likely substances responsible for acute signs and symptoms. They can also guide appropriate testing and advise on specialized laboratories where testing for these substances can be performed. If the original product is available, it can often be examined through forensic analytic laboratories (eg, drug enforcement agencies).
•Hair testing – Unlike testing of urine, hair testing typically detects non-acute substance exposures (weeks to months) and are most appropriate for forensic purposes to establish remote drug exposure such as asymptomatic children suspected of substance exposure in whom more routine toxicology drug testing is negative [4,12]. Testing of hair specimens should only be performed by laboratories that routinely handle alternative specimens. Hair testing should not be used to evaluate for acute exposure or intoxication [12].
A minimum of two inches (5 cm) of hair is typically required. When testing specifically for substance use or systemic exposure, pre-test hair washing to remove external substance residue from hair shaft surfaces is necessary. On the other hand, this step may be omitted in a separate sample to establish environmental exposures in support of drug endangerment, particularly for those cases involving substance manufacturing (eg, methamphetamine) that results in aerosolized substance residue [4,5,48].
Toxicology testing specific to infants with prenatal substance exposure and drug-facilitated sexual assault are discussed in detail separately. (See "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Clinical features and diagnosis" and "Evaluation and management of adult and adolescent sexual assault victims in the emergency department".)
Interpretation of results — A diagnosis of an SEC is supported by the following toxicology test results:
●Illicit drug or substance exposure – Any confirmed illicit drug/substance exposure, based upon history, clinical features, and/or toxicology testing indicates an SEC.
●Legal nonpharmaceutical drug or substance exposure – Certain substances that are legal for adult use (such as ethanol or, in certain jurisdictions, marijuana) nevertheless indicate substance exposure when testing confirms them as causing intoxication or exposure in young children [49].
●Certain prescription drug exposures – Exposure to prescription drugs not intended for treatment of a specific condition in the child and permitted for the child's recreational use, intentionally administered to child by the primary caregiver, or caused by lack of supervision due to primary caregiver intoxication impairment.
Careful interpretation of results considers the patient's clinical findings and detailed knowledge of the specific toxicologic testing that has been performed. Consultation with a medical toxicologist or clinical lab specialist with similar expertise is essential. Misinterpretation of toxicological test results can have serious medical consequences (eg, missed diagnosis of an SEC due to a false negative or not considering substances not tested on the assay) or social consequences, such as a child protection investigation that may lead to removal of the child from the home and arrest of the primary caregiver based upon a false positive result:
●Urine testing – The table provides common causes of false positive results for urine drugs of abuse screens (table 8). The interpretation of urine drugs of abuse testing of urine is discussed in detail separately. (See "Testing for drugs of abuse (DOAs)", section on 'Interpreting results'.)
●Hair testing – Factors like external contamination, hair structure, growth rate, melanin content and cosmetic alteration may influence results [4,41,49,50]. For asymptomatic children undergoing hair testing for forensic purposes, specimens should only be performed by experienced laboratories. A minimum of two inches (5 cm) of hair is typically required. When testing specifically for substance use or systemic exposure, pre-test hair washing to remove external substance residue from hair shaft surfaces is necessary. On the other hand, this step may be omitted in a separate sample to establish environmental exposures in support of drug endangerment, particularly for those cases involving substance manufacturing leading to aerosolized substance residue (eg, methamphetamine) [4,5,48].
Incorporation of substances into hair occurs by several possible routes [4]:
•Systemic circulation and follicular capillary supply
•Sweat and/or sebum deposition
•Environmental, superficial external hair contamination
Furthermore, substance incorporation into hair varies by affinity to hair melanin and lipophilicity, hair growth rates, timing relative to exposure, and performance of prewash steps. Metabolite detection may also not be indicative of systemic exposure because tissues around the hair follicle contain enzymes that may metabolize parent substances into metabolites (eg, cocaine to benzoylecgonine) when exposed to air or moisture after collection [48]. In addition, the frequency and degree of substance exposure cannot be predicted based on hair testing alone. For this reason, hair follicle testing of children is not recommended as an effective method of confirming caregiver use and impairment [12].
DIFFERENTIAL DIAGNOSIS — It is essential to consider substance exposure for all children who present with [18,27,28,38,51]:
●Burns and/or explosive injuries from house fires
●Physical, sexual, emotional abuse or neglect
●"Unintentional poisoning" including those with exposure to chemical precursors of illicit drug manufacturing (eg, methamphetamine) (see 'Findings of substance exposure' above)
Investigation by law enforcement and fire safety officials can confirm the presence of possible clandestine drug manufacturing in the child's home. In addition, for children with suspected methamphetamine exposure, urine and hair toxicology testing for amphetamines are frequently positive. (See 'Toxicology testing' above.)
In pediatric patients undergoing toxicologic testing because of suspicion of substance exposure or impaired caregivers, substance exposure needs to be differentiated from other reasons for positive results:
●False positive results – For children with positive urine drug screens, correct interpretation relies upon confirmation with advanced laboratory methods (eg, gas chromatography with mass spectrophotometry [GC-MS], high performance liquid chromatography [HPLC] with MS, or HPLC with tandem MS) and assessment of whether the child has been exposed to substances that can cause false positive urine drug testing results (table 8). (See "Testing for drugs of abuse (DOAs)", section on 'What does a positive DOA test result mean?'.)
●Therapeutic drug administration or use – For children or possibly impaired caregivers with true positive toxicology testing, the physician should establish whether the result is explained by therapeutic drug administration for conditions such as chronic pain or epilepsy.
●Recreational drug use – For adolescents with positive toxicology testing, it is important to determine if the results are due to the patient's recreational use rather than caused by the caregiver's actions.
SUMMARY AND RECOMMENDATIONS
●Terminology – The "substance-exposed child" (SEC, also called the "drug endangered child") refers to infants and children harmed or at risk of harm by drugs or other substances and/or an unsafe home environment related to parent or caregiver substance use. (See 'Terminology' above.)
●Clinical features – The presentation of the SEC occurs on a continuum varying from physical manifestations of life-threatening intoxication to asymptomatic children with positive toxicology testing (see 'Findings of substance exposure' above):
•Poisoning – Signs of unintentional or malicious poisoning may be caused by agents such as opioids, cannabis, or methamphetamine (table 1). Symptoms exhibited by young children after cannabis and methamphetamine exposure may vary from classic toxidromes. For example, children exposed to concentrated forms of cannabis may present with coma and respiratory depression rather than the expected findings of mild sympathomimetic effects with vomiting, conjunctival injection, nystagmus, and/or ataxia; instead of the typical sympathomimetic effects, children with cocaine or methamphetamine poisoning may exhibit lethargy.
•Chemical burns, caustic ingestion, or inhalational injury – Although uncommon, hazardous chemical exposure in children has been described, typically in drug-endangered children living in houses used as clandestine methamphetamine laboratories.
•Exposure to drug paraphernalia – Contact with drug paraphernalia can cause skin or needlestick injuries from razor blades or syringes.
•Impaired caregiver or evaluation after rescue from a clandestine drug laboratory (potential exposure) – In this circumstance, the SEC may be asymptomatic or minimally symptomatic but exposed. Such occult exposures require detection by toxicology testing.
In addition to evidence of substance exposure, the SEC may have findings of physical (table 3 and table 4), sexual (table 5), or emotional child abuse and/or neglect. (See 'Signs of child abuse' above.)
●Diagnosis and diagnostic evaluation – The diagnosis of an SEC is based on evidence of harm or risk of harm caused by substance exposure resulting from caregiver actions. Key findings include (see 'Approach' above):
•Poisoning or substance exposure – Exposures range from acute symptomatic intoxication to chronic asymptomatic or minimally symptomatic exposure to hazardous drugs and chemicals caused by the caregiver's substance use disorder or illicit drug activities. (See 'History' above and 'Physical examination' above.)
•Co-existing child abuse – Signs include evidence of sexual abuse/assault (table 5) or sex trafficking (table 7), physical abuse (table 6), emotional abuse and/or neglect. (See 'History' above and 'Physical examination' above.)
•Unsafe environment – The child is determined to be at risk because of primary caregiver impairment and/or an unsafe home environment related to the caregiver's substance use or manufacturing. (See 'Family interaction' above.)
•Social history – The primary caregiver's substance use has led to housing or food insecurity.
•Toxicology testing – Although an essential component of the evaluation, healthcare professionals should not rely solely on a positive or negative toxicology test to make the diagnosis; test results should be interpreted within the broader context of home environment and the child's safety. Indications for testing include (see 'Toxicology testing' above):
-History or physical findings of drug or illicit substance poisoning or exposure in the child, including history obtained from objective third party observers (eg, social workers, prehospital medical personnel, and/or police)
-Parent/primary caregiver impairment (directly observed by the clinician, reported by an objective observer, or suspected by history)
-Concern for co-occurring physical, sexual, emotional abuse and/or neglect (see "Physical child abuse: Diagnostic evaluation and management", section on 'Toxicology')
Specific toxicology testing varies based upon the type of suspected exposure (acute or chronic); consultation with a medical toxicologist or clinical laboratory specialists with similar expertise increases the likelihood of substance detection (see 'Toxicology testing' above):
-Acute substance exposure – Children suspected of acute exposures should undergo urine drug screening with confirmation by advanced methods if initial screening is positive. Substances detected, time frame for detection after acute exposure, and potential causes of false positives on typical urine drugs of abuse screens are summarized in the table (table 8). Based on history and regional illicit drug trends (eg, fentanyl, fentanyl analogs, cathinones, or synthetic cannabinoids), more comprehensive testing may be indicated.
-Occult/chronic substance exposure – In addition to urine drugs of abuse testing, asymptomatic children with possible chronic exposures may warrant hair testing for forensic purposes performed by a laboratory experienced in toxicologic testing of alternative specimens.
Careful interpretation of results considers the patient's clinical findings and detailed knowledge of the specific toxicologic testing that has been performed. Consultation with a medical toxicologist or clinical lab specialist with similar expertise is essential. Substance exposure needs to be differentiated from other reasons for positive results. (See 'Interpretation of results' above and 'Differential diagnosis' above.)
●Reporting – Children suspected of substance exposure warrant urgent consultation with a social worker and, whenever available, involvement of a multidisciplinary child abuse team. In many jurisdictions, reporting substance exposure to child protective services and, if a separate report is required, law enforcement is also required. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
